Dover Nclex

The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:

keeping the bed in the lowest possible position.

The licensed practical nurse is admitting a client to the medical-surgical floor. She asks the client if he has an advance directive . The client responds by saying, "I don't know what you mean." How should the nurse respond?

"An advance directive is a document that states your wishes about health care.

Which client statement indicates a need for further teaching?

"My breakouts are exacerbated by eating fatty foods."

A client is receiving terbutaline (Brethine) to stop preterm labor. The physician plans to discharge the client in the morning with a terbutaline infusion pump. Which instruction should the nurse include when teaching the client about the drug?

"Assess the insertion site for signs of infection."

The licensed practical nurse is teaching a client with right-sided weakness proper cane use. Which instruction should the nurse include in her teaching?

"Hold the cane on the opposite side from the injury."

The nurse is reinforcing the education provided for the client and spouse regarding electroconvulsive therapy. What statement made by the client would indicate that further education is required?

"I will have no further episodes of depression after I have the procedure."

A client develops a pulmonary embolism after total knee replacement surgery and must be converted from heparin to warfarin anticoagulant therapy. What should the nurse inform the client is the reason for the change in the treatment plan?

"Prothrombin time (PT) and international normalized ratio (INR) will be checked for dose adjustment."

The nurse is working in a pediatric emergency department. Which client would be seen first?

5-year-old with orbital cellulitis The 5-year-old with orbital cellulitis should be seen first because significant damage to the optic nerve can occur, causing permanent vision problems or total loss of vision.

Which neonate is at greatest risk for the nursing diagnosis Imbalanced nutrition: Less than body requirements related to poor sucking?

A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day

A registered nurse (RN) on the oncology floor is busy with one client, so she delegates care of another client to her coworker, a licensed practical nurse (LPN). The client that the LPN begins caring for requires a 3-hour chemotherapy infusion. Which of the following actions is in accordance with her state's nurse practice act?

A chemotherapy-certified RN must begin the chemotherapy infusion; then the LPN may monitor the client.

A nurse is caring for a client who required chest tube insertion for pneumothorax. To confirm pneumothorax resolution, what should the nurse anticipate the client will require?

A chest X-ray

During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. Which physiological response should the nurse monitor this client for?

A drop in the client's heart rate During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it, in turn, may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate leading to syncope. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.

A nurse places an object in the hand of a client with Alzheimer's disease (AD) and asks the client to identify the object. Which term represents the client's inability to name the object?

Agnosia Agnosia is the inability to recognize familiar objects. Aphasia is characterized by an impaired ability to speak. Apraxia refers to the client's inability to use objects properly. All three impairments usually occur in stage 3 of Alzheimer's disease. Perseveration is continued repetition of a meaningless word or phrase that occurs in stage 2 of Alzheimer's disease.

A client's blood studies reveal a deficiency in all of the blood's formed elements. The physician suspects that the client's bone marrow is failing to generate enough new cells. Which disorder is most likely affecting this client?

Aplastic anemia

A neonate begins to gag and turns a dusky color. What should the nurse do first ?

Aspirate the neonate's mouth then nose with a bulb syringe.

A 35-year-old client is brought to the emergency department with second- and third-degree burns over 15% of his body. His admission vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client?

Begin an I.V. infusion of lactated Ringer's solution. Administer 6 mg of morphine I.V. Administer tetanus prophylaxis, as ordered.

A 5-year-old child suspected of having leukemia is admitted to the hospital for diagnosis and treatment. Which tests aid in diagnosing leukemia?

Bone marrow aspiration and analysis 2. Complete blood count 3. Lumbar puncture

A hospital is conducting a root cause analysis for a serious medication error made by a nurse that injured a client. What is the expected outcome of the root cause analysis?

Cause of error identified through system wide analysis

In which child population would the nurse be alert for giardiasis, the most common parasitic intestinal infection in the United States?

Children attending group day care or nursery school

A histamine (H2) receptor antagonist is prescribed for a client with recurrent gastrointestinal discomfort. The nurse is instructing the client from a medication pamphlet and highlights which medications in this classification? Select all that apply.

Cimetidine Ranitidine Nizatidine Famotidine

A client diagnosed with cirrhosis of the liver caused by alcohol abuse is noncompliant with the prescribed protein-restricted diet. After a friend finds the client semiconscious at home, the client is admitted to the hospital. When initial laboratory test results show an elevated ammonia level, he's diagnosed with hepatic encephalopathy . The physician prescribes lactulose, 200 gram diluted in 700 ml of tap water, given as a retention enema every 4 hours. For which other condition would the nurse expect to administer lactulose?

Constipation

A client is evaluated for hypertension. The physician prescribes atenolol, 50 mg by mouth daily. Atenolol should have which therapeutic effect on the client?

Decreased cardiac output and systolic and diastolic blood pressure

The Women's Clinic nurse is instructing a client on the proper use of an applicator to instill vaginal cream. Which of the following instructions is applicable when teaching a client about vaginal medication insertion?

Direct the tip of the applicator toward the sacrum.

A client taking a new prescription for propranolol calls the clinic to report a weight gain of 3 lbs (1.36 kg) within 2 days, shortness of breath, and swollen ankles. What is the nurse's best action?

Due to fluid accumulation have the client assessed for worsening heart failure by the physician.

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis . Which drug will be used to test for this disease?

Edrophonium

A nurse is caring for a client who has a tracheostomy and a temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

Endotracheal suctioning

At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase (Pancrease). At a follow-up visit, which finding suggests the need for further teaching?

Fatty stools

A client with a history of bipolar disorder came to the hospital in the manic phase. The client has not taken lithium for 2 weeks. Which finding would the nurse be likely to see?

Flight of ideas

A dystonic reaction can be caused by which medication?

Haloperidol

Which characteristic should a nurse expect to see on a normal cardiac rhythm strip obtained from an adult client?

Heart rate of 88 beats/minute

An elderly client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism?

Homans'

A nurse determines that a client with antisocial personality disorder is beginning to practice several socially acceptable behaviors in the group setting. Which behavior if observed by the nurse would indicate this is taking place?

Improved self-esteem

According to Erikson's theory of development, chronic illness can interfere with which stage of development in an 11-year-old child?

Industry versus inferiority

The nurse is presenting a lecture on vertigo at a community setting. The nurse will include that the client with vertigo may have a problem with which portion of the ear?

Inner ear

Which of the following nutritional deficiencies may delay wound healing?

Lack of vitamin C

The nurse is informed by the secretary that her client will soon be returning from the postanesthesia care unit. What should the nurse do when preparing a surgical bed?

Leave the bed in the high position when finished

What's the best way for a nurse to position a 3-year-old child with right lower lobe pneumonia?

Left side-lying

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are found in the carotid sinus and aorta. Which other area should the nurse mention as a site of arterial baroreceptors?

Left ventricular wall

A client with cancer is being evaluated for possible metastasis. Which of the following is a common metastasis site for cancer cells?

Liver

A nurse is caring for a client who just had surgery. What is the nurse's highest priority for this client?

Maintain a patent airway.

Which nursing intervention is important for the nurse to perform preoperatively for a child with appendicitis?

Maintain complete bed rest.

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign , and Kernig's sign . What does Brudzinski's sign indicate ?

Meningeal irritation

A client with chronic schizophrenia who takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, tachycardia, altered consciousness, and diaphoresis. These findings suggest which life-threatening reaction?

Neuroleptic malignant syndrome

A primipara client at 32 weeks' gestation comes to the hospital complaining of vaginal bleeding. She has soaked one peri-pad. She has no pain or cramps. What's one possible cause of the vaginal bleeding?

Placenta previa

A nurse is preparing to teach a group of school-age children about injury prevention. Which intervention is most appropriate?

Play group games involving sports safety equipment.

The nurse obtains laboratory results on assigned clients during morning report. Which results needs to be immediately reported to the physician?

Potassium level 6.2 mg/dL

A client needs to have a fecal occult blood test (Hemoccult) performed on three consecutive bowel movements. To prepare the client for this test, the nurse provides information about the required dietary restrictions. For 4 days before the test, which foods should the client avoid?

Poultry, red meat, and turnips

A client has just been diagnosed with having a hydatidiform mole. When reviewing the client's medical record, what is the most significant risk factor?

Prior molar gestation

A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis . Which nursing intervention would be appropriate ?

Providing small, frequent meals

A client with pneumonia is admitted to the medical-surgical unit. Which painless, noninvasive procedure used to measure SaO2 will the nurse perform on this client?

Pulse oximetry

A client who is 27 weeks' pregnant arrives at her health care provider's office reporting fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. About which condition does the nurse anticipate reinforcing education?

Pyelonephritis

A 20-year-old client whose pregnancy is confirmed at a clinic says her husband will be excited but is concerned because she herself isn't excited. She fears this feeling may mean she'll be a bad mother. What should the nurse's response be to the client?

Reassure the client that such feelings are normal in the beginning of pregnancy.

A disaster has been reported a few miles from an area hospital. Which of the following roles should be assigned to the LVN/LPN?

Render first aid to injured clients.

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

Restricting fluids To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.

A nurse is caring for a client with paranoid personality disorder. The nurse would expect to observe which condition?

Secretiveness

A nurse is educating the parents of a child with a urinary tract infection. Which factor should the nurse indicate contributes to urinary tract infection?

Short urethra

A client in labor is prescribed oxytocin and asks the nurse, "What's this medication for?" The nurse would incorporate knowledge of which action in the response?

Stimulates labor and prevents hemorrhage

A nurse is evaluating a neonate. How should she evaluate the rooting reflex?

Stroke the neonate's cheek.

A nurse is assigned to care for an elderly client diagnosed with labyrinthitis (inflammation of the inner ear). Which findings should the nurse expect in the client?

Sudden onset of incapacitating vertigo, usually accompanied by nausea and vomiting

A nurse is explaining the Snellen Chart to a group of nursing students. Which statement about a client with 20/40 vision would the nurse include in her explanation?

The client can read from 20' (6 m) what a person with normal vision can read from 40'.

Which goal for the family of a client with antisocial disorder should the nurse stress in education?

The family must stop reinforcing inappropriate negative behavior

A nurse on the pediatric floor is caring for a toddler. What should the nurse keep in mind about toddlers?

They express negativism.

A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. Which information should be provided to the school?

This is an appropriate request and arrangements will be made as soon as possible. Screening for scoliosis should begin at age 8 and should be performed yearly thereafter. Screening for scoliosis involves inspection of the spine and use of a scoliometer, both of which can be done in a school setting.

A school-age child's family asks the nurse to describe palliative care. Which statement best describes palliative care?

Total care given when disease doesn't respond to curative treatment

A nurse immediately tells the truth about a medication error that she made. This nurse is following which ethical principle?

Veracity

A healthy client comes to the clinic for a routine examination. When auscultating lower lung lobes, the nurse anticipates which type of breath sound?

Vesicular

A dopamine receptor agonist such as bromocriptine (Parlodel) relieves muscle rigidity caused by antipsychotic medication by:

activating dopamine receptors in the CNS.

A nurse collects data on a client who is postoperative thyroid surgery. The client has a positive Chvostek's sign. Which laboratory finding supports the presence of this finding?

calcium 7.1 mg/dL (1.77 mmol/L)

The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:

fat

A nurse is caring for a client with acute respiratory distress syndrome (ARDS). Which laboratory finding should the nurse expect in the early stages of this disease?

partial pressure of arterial oxygen (PaO2) 75%

A nurse is reinforcing the education plan with the father of a child who has asthma that's triggered by dust mite allergy. Which statement by the father indicates that education has been effective?

"I'll wash all of the bedding in hot (130° F) water every week."

The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed?

Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.

A client with high blood pressure is receiving an antihypertensive drug. The nurse knows that antihypertensive drugs commonly cause fatigue and dizziness, especially on rising. When developing a client teaching plan to minimize orthostatic hypotension , the nurse should include which instruction?

"Flex your calf muscles, avoid alcohol, and change positions slowly."

The nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will prescribe daily supplements of calcium and:

vitamin D. Typically, clients with hypoparathyroidism are prescribed daily supplements of vitamin D along with calcium because calcium absorption from the small intestine depends on vitamin D. Hypoparathyroidism doesn't cause a deficiency of folic acid, potassium, or iron. Therefore, the client doesn't require daily supplements of these substances to maintain a normal serum calcium level.

For a client with a sleep pattern disturbance, the nurse could use which measure to promote sleep?

Play soft or soothing music.

A preschooler has vomiting, diarrhea, and a potassium level of 3.0 mEq/L. The physician prescribes an I.V. infusion of dextrose 5% in water and half-normal saline solution with 10 mEq of potassium chloride. The nurse knows that a child with vomiting and diarrhea needs fluids and potassium chloride to:

meet physiologic needs.

When measuring the radial pulse of a client with known aortic insufficiency, the nurse detects a "water-hammer" or Corrigan's pulse . What are the characteristics of this pulse?

Bounding, with a rapid rise and fall

Within hours after suffering a massive myocardial infarction, a client experiences cardiogenic shock. All vital functions are being monitored closely; an intra-arterial catheter has been inserted to detect changes in arterial blood pressure. Which statement comparing intra-arterial and cuff blood pressure readings is accurate?

Intra-arterial readings should be at least 10 mm Hg higher than cuff readings.

A client with altered mental status fell out of bed while hospitalized and now the family wants to sue the facility. Which elements must be proven by the family's attorney in this case to result in a guilty verdict of professional negligence?

Duty, breach of duty, damages, and causation

A client is diagnosed with pericarditis . The nurse anticipates that the client may exhibit which signs and symptoms?

Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. All other symptoms may result from acute renal failure.

When preparing a teaching plan for mother with an infant, which important information would the nurse include? Select all that apply.

Infants require 1.5 to 2 ounces of breast milk or formula per pound of body weight daily. Do not give regular cow milk to an infant younger than one year of age.

A nurse is verifying orders from a health care provider. Which diet will the nurse discuss with child and family related to a new diagnosis of celiac disease?

No-gluten diet The intestinal cells of individuals with celiac disease become inflamed when the child eats products containing gluten, such as wheat, rye, barley, or oats. The child with celiac disease needs normal amounts of fat and protein in the diet for growth and development. Omitting phenylalanine products would be appropriate for the client with phenylketonuria.

A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria . The nurse reports this to the physician immediately because the client probably is experiencing:

a hemolytic allergic reaction caused by an antigen reaction.

Before administering digoxin (Lanoxin) to a client, a nurse reviews information about the drug. She learns that after digoxin is metabolized, the body eliminates remaining digoxin as unchanged drug by way of the:

kidneys.

A cognitively alert client is scheduled for a coronary artery bypass graft surgery in the morning. The nurse checks the chart for preoperative orders and finds that the surgical consent form hasn't been signed. Which of the following is the best action for the nurse to take?

Notify the surgeon.

When preparing a client, age 50, for surgery to treat appendicitis , the nurse formulates a nursing diagnosis of Risk for infection related to inflammation perforation , and surgery. Based on which evidence, why is the nurse selecting this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored . What should the nurse do next?

Prepare for immediate delivery of the baby